Make EPI an ‘Essential Programme on Immunization’

Context:

The year 2024 commemorates 50 years since the launch of the Expanded Programme on Immunization (EPI) by the World Health Organization (WHO) in 1974. 

About Expanded Programme on Immunization (EPI):

• Introduction: The EPI was introduced in 1974 as the eradication of smallpox virus was on the horizon, and there was a need to leverage the then immunization infrastructure and a trained workforce to expand the benefit of available vaccines. 
  • India launched the EPI in 1978, which was later renamed as the Universal Immunization Programme (UIP) in 1985. 

• Significant Progress: Globally, and in India, there has been significant progress in terms of the impact of immunisation and vaccines. 
  • Over the years, the vaccination coverage in India has increased, both nationally and State-wise. 
  • While in 1974, there were vaccines to prevent six diseases, now there are vaccines against 13 diseases which are universally recommended and vaccines against 17 additional diseases are recommended for a context-specific situation. 
    • 13 Universally Recommended vaccines are Bacillus Calmette-Guérin (BCG), diphtheria, pertussis, tetanus, Haemophilus influenzae type B (Hib), Hepatitis B (HepB), polio, measles, rubella, pneumococcal disease (PNC), rotavirus (Rota), human papillomavirus (HPV), and COVID-19 (for adults).

Significance & Achievement of Expanded Programme on Immunization (EPI):

• On DPT: The children with three doses of DPT, a tracer indicator of coverage, has been rising over these years. 
  • In the early 1970s, around 5% of children in low- and middle-income countries had received three doses of DPT, which increased to 84% in 2022 at the global level. 
• Eradication of Diseases: Smallpox has been eradicated, polio eliminated from all but two countries and many vaccine preventable diseases have nearly disappeared. 
• High Coverage: Since the launch of EPI, studies have shown that vaccines have saved millions of lives and prevented billions of hospital visits and hospitalisations. 
  • In nearly all low- and middle-income countries, including India, the immunization programme remains a success among all government initiatives, nearly always with far greater coverage than any other health programme. 
  • In India, the coverage has increased every passing year and in 2019-21, 76% of children received the recommended vaccines.
• Cost-effective: Economic analyses have estimated that vaccines are highly cost-effective interventions, with every single dollar (or rupee) of expenditure on vaccination programmes ensuring a seven to 11-fold return.
• Greater Utilisation: In mixed health systems with both the public and private sector delivering services, immunization often remains the only health intervention with greater utilization from the government sector. 
  • Example: In India, the share of the private sector in overall health services is nearly two thirds; however, nearly 85% to 90% of all vaccines are delivered from government facilities. 
• An Indicator: Experts often argue that the immunization coverage is a tracer indicator of the possible highest coverage any government intervention can achieve in a given setting.

Evolution & Background of Vaccine Development:

• 1798: The first vaccine against smallpox in 1798.
• In Late Nineties: The first anti rabies vaccine, cholera, and typhoid vaccines developed between 1880s to mid 1890s were primarily for adults. 
• 1897: The first vaccine ever developed in any part of the world against plague (in 1897) was from India. 
• 1951: The BCG vaccine (against tuberculosis) was first introduced in a nationwide campaign in 1951. 
• 2023: In late 2023, India launched a pilot initiative of adult BCG vaccination as part of efforts to ‘end TB’ from India. The COVID-19 vaccination of the adult population has made the public sensitized to the need for and the benefits of adult vaccination. 
• Availability for All-age Groups:
  • Since 1798, vaccines have been available for individuals of all age groups, including adults. 
  • Vaccine against plague was meant for individuals across all age groups.
  • BCG vaccine was also administered to the adult population.
  • Influenza vaccines have always been administered to adults and children alike. 
  • Priority for Children:
    • Considering that children are most vulnerable from vaccine-preventable diseases, they have rightly been prioritised for vaccination. 
    • Also, a few decades ago, the supply of vaccines was limited, and the financial resources and trained workforce that governments had were scarce. Thus, vaccines were aimed to be delivered to the population groups which would benefit from them the most — children.

Rising Challenges:

• UNICEF Report: In early 2023, UNICEF’s ‘The State of the World’s Children’ report revealed a concerning trend- for the first time in more than a decade, the childhood immunisation coverage had declined in 2021.
• Zero Dose: In 2022, globally, an estimated 14.3 million children were zero dose (did not receive any recommended vaccine) while another 6.2 million children were partially immunised. 
• Reasons: There are persisting inequities in coverage by geography, socio-economic strata and other parameters, which demand urgent interventions.

Way Forward:

• Policy & Technical Discussions: There are some initial policy and technical discussions regarding expanding immunisation coverage in additional populations. 
• Expansion of Coverage: The Indian government needs to consider providing recommended vaccines for a wider section of adults and elderly population. 
  • The recent announcement on HPV vaccines for teenage girls is a good start. 
  • The introduction of new vaccines in national programmes contributes to increased coverage of all existing vaccines. Therefore, it is likely that expanding coverage of vaccines for adults and the elderly may result in improved coverage with childhood vaccines and reduced vaccine inequities. 
• Focus on Affordability: Considering that vaccines are highly cost effective, once recommended by the National Technical Advisory Group on Immunization (NTAGI), vaccines for all age groups should be made available as free at the government facilities.
• Recommendations on the Vaccine Usage: The NTAGI in India, which provides recommendations on the use of vaccines should start providing recommendations on the use of vaccines in adults and the elderly. 
  • It is crucial that once a vaccine is recommended by the government body, the coverage is likely to be far greater than if the vaccines are not recommended by the government.
• Addressal to Vaccine Hesitancy: The prevailing myths and misconceptions about vaccines must be proactively addressed to tackle vaccine hesitancy. 
  • The government must consider the help of professional communication agencies to dispel myths (and in a layperson’s language and with the use of social media). 
  • This also requires citizens to learn and educate themselves about these vaccines from reliable sources.
• Increase Awareness: Various professional associations of doctors (community medicine experts, family physicians and paediatricians) should work to increase awareness about vaccines among adults and the elderly. 
  • Physicians treating patients with any disease should use the opportunity to make them aware of vaccines.
• Evidence Generation: Medical colleges and research institutions should generate evidence on the burden of diseases in the adult population in India.
• Focused Policies: It would be imperative that government policies now focus on the vaccination of adults and the elderly, as is happening in many countries. 

Conclusion:

India’s EPI has made major progress and it is arguably a time for another independent national level review of the UIP in India, engaging key partners and international experts. This is a right opportunity to start a new journey for another expansion of the programme with focus on zero dose children, addressing inequities in vaccine coverage and offering vaccines to adults and the elderly in India. It is time to make EPI an ‘Essential Program on Immunization’.